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Principles of Microsurgery


Microsurgery uses the operating room microscope or high-powered loupe magnification to facilitate the microvascular surgical techniques used to anastomose small vessels and nerves.
 Microsurgical reconstruction is used for complex reconstructive surgery problems when other options (eg, primary closure, healing by secondary intention, skin grafting, and local or regional flap transfer) are not adequate.

The field of microsurgery began with the introduction of the operating microscope, when Jacobson and Suarez described the anastomosis of blood vessels. In the 1960s, as microsurgical techniques were perfected, increasing success was seen with digital artery repairs and finger replantation. This laid the foundation for microsurgical composite tissue transfer, which became popular in the 1970s.

In the 1980s, an emphasis was placed on improved function with autologous tissue transplantation, which is exemplified in mandibular reconstructions for cancer. Composite grafts consisting of soft tissue and bone aided in stabilizing the mandible, assisted with mastication, and allowed reliable coverage during the postoperative period, when radiation usually was required. Today, microsurgical techniques have become an integral part of the armamentarium for plastic surgeons, allowing for soft-tissue coverage and function after trauma or oncologic resections.

Microsurgery may not be the best solution for all reconstructive dilemmas and usually is not the first choice in the reconstructive ladder. However, it can offer the reconstructive surgeon an important tool for achieving complex reconstruction by proceeding with free tissue transfer from distant sites.
Free tissue transfer includes flaps such as the following:

Isolated transfers

Composite tissue transfers

Functioning free muscle transfers

bone grafts

Toe transplantation

In addition, specific tissue transfers such as neural grafts or vein grafts are also considered free tissue transfer. In specific cases, such as large defects of the face after tumor resection, free tissue transfer may be the best option for closure of the defect.

Reconstructive microsurgery has entered a stage where, because of continued developments in technology and a better understanding of the anatomy, anastomosis of very small vessels (0.3 mm) is possible. These highly challenging procedures are referred to in the literature as supermicrosurgery.
They allow anastomosis of perforator flaps such as the medial plantar flap to perforator recipient vessels.
 Additional applications include complex digit reimplantation and lymphatic anastomosis.

Although microsurgery continues to develop, the basic principles of microsurgery remain the same:

Select patients carefully

Develop a careful preoperative plan and a back-up plan

Use a well-defined workhorse flap

Obtain full patient consent

Pay attention to intraoperative details

Employ meticulous microsurgical technique

Remain vigilant during postoperative care

This article outlines the basics of microsurgery, preoperative planning, specific operative techniques, and postoperative care. In addition, it describes some of the flaps most commonly used for microsurgical reconstruction.

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